Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland.
Diabetes Metab Res Rev. 2012 Feb;28 Suppl 1:40-5. doi: 10.1002/dmrr.2233.
Peripheral arterial disease is common among diabetic patients with renal insufficiency, and most of the diabetic patients with end-stage renal disease (ESRD) have peripheral arterial disease. Ischaemia is probably overrepresented as an etiological factor for a diabetic foot ulcer in this group of patients compared with other diabetic patients. ESRD is a strong risk factor for both ulceration and amputation in diabetic patients. It increases the risk of nonhealing of ulcers and major amputation with an OR of 2.5-3. Renal disease is a more important predictor of poor outcome after revascularizations than commonly expected. Preoperative vascular imaging is also affected by a number of limitations, mostly related to side effects of contrast agents poorly eliminated because of kidney dysfunction. Patients with renal failure have high perioperative morbidity and mortality. Persistent ischaemia, extensive infection, forefoot and heel gangrene, poor run-off, poor cardiac function, and the length of dialysis-dependent renal failure all affect the outcome adversely. Despite dismal overall outcome, recent data indicate that by proper selection, favourable results can be obtained even in ESRD patients, with the majority of studies reporting 1-year limb salvage rates of 65-75% after revascularization among survivors. High 1-year mortality of 38% reported in a recent review has to be taken into consideration, though. The preferential use of endovascular-first approach is attractive in this vulnerable multimorbid group of patients, but the evidence for endovascular treatment is very scarce. The need for complete revascularization of the foot may be even more important than in other patients with ischaemic ulcerated diabetic foot because there are a number of factors counteracting healing in these patients. Typically, half of the patients are reported to lose their legs despite open bypass. To control tissue damage and improve chances of ulcer healing, one should understand that early referral to vascular consultation is necessary.
周围动脉疾病在肾功能不全的糖尿病患者中很常见，大多数终末期肾病（ESRD）的糖尿病患者都有周围动脉疾病。与其他糖尿病患者相比，缺血可能在这群患者的糖尿病足溃疡的病因中占更大比例。ESRD 是糖尿病患者溃疡和截肢的强烈危险因素。它使溃疡和大截肢的非愈合风险增加 2.5-3 倍。与通常预期的相比，肾病是血管重建后不良结局的更重要预测因素。术前血管成像也受到许多限制，主要与肾功能障碍导致造影剂副作用难以消除有关。肾衰竭患者围手术期发病率和死亡率高。持续性缺血、广泛感染、前足和足跟坏疽、流出道不良、心功能差和透析依赖的肾衰竭时间都对结局产生不利影响。尽管整体预后不佳，但最近的数据表明，通过适当选择，即使在 ESRD 患者中也可以获得良好的结果，大多数研究报告在幸存者中血管重建后 1 年的肢体存活率为 65-75%。尽管如此，仍应考虑到最近一篇综述中报告的 1 年高死亡率 38%。在这个脆弱的多病共存的患者群体中，优先采用血管内治疗方法很有吸引力，但血管内治疗的证据非常缺乏。在这些患者中，可能需要更彻底地重建足部的血管，因为有许多因素会影响溃疡愈合。通常，有一半的患者尽管进行了开放旁路手术，但仍会失去双腿。为了控制组织损伤并提高溃疡愈合的机会，应该理解早期向血管科咨询是必要的。
